It is important to take into account barriers to treatment such as economic, geographic, cultural, and stigma-related issues; distrust; and past persecutory experiences. Idioms of distress are the characteristic way in which members of different cultures describe what is wrong and which may differ from the expressions found in mainstream American culture. It is also very important to explore the patient’s history for adverse life events and to listen to the metaphors or therapeutic stories for adverse previous personal and medical experiences. In many cases, the patient’s “life-meaning story” is closely related to previous traumas that account for treatment resistance. In some cases, the patient fears a repetition of these traumas, such as in the case of psychiatric hospitalization, which may elicit fears of oppression, abuse, and incarceration.

Acknowledgment—I am grateful to David Lopez, MD, and Jennifer Downey, MD, of the American Academy of Psychoanalysis and Dynamic Psychiatry (AAPDP) for their invitation to write this article and for their review of the article. The AAPDP is the affiliate society of the American Psychiatric Association dedicated to all aspects of psychodynamic psychiatry. Its mission is to promote psychodynamic understanding when evaluating and treating patients in clinical practice, medical education, and residency training.

Pages

Dr. Rothe is Professor of Psychiatry and Public Health at the Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, and Immediate Past Chair of Scientific Programs, American Academy of Psychoanalysis and Dynamic Psychiatry.

Dr. Rothe reports no conflicts of interest concerning the subject matter of this article.